'Distorted perception of risk' key factor in 2019 plane crash in Sachigo Lake First Nation, TSB says
Company says changes implemented after crash made 'immediate and profound' impact on safety culture
A work subculture that encouraged taking unnecessary risks at a northern Ontario airline was a key factor in a 2019 crash landing in Sachigo Lake First Nation, the Transportation Safety Board (TSB) has found.
The TSB report released Thursday found risky decisions the pilot took that December day stemmed from a "distorted perception of risk resulting from successful past experience in similar situations" and "the results-oriented subculture of some of North Star Air's DC3-TP67 pilots."
In December 2019, the North Star Air Ltd. DC3 plane was flying a cargo flight from Red Lake to Sachigo Lake First Nation in northwestern Ontario. Despite the conditions and being trained for instrument-guided flying, the pilot tried to land using what's known as visual flight rules for clear conditions, when the person should have been relying on the instruments.
As the pilot attempted to land the plane, it hit the ground about 200 metres short of the runway, wrecking the plane. No one was hurt.
"The captain likely experienced attentional narrowing while carrying out a high-workload visual approach at a very low altitude," the report says.
"This most likely resulted in an inadvertent but controlled descent that was not detected until the aircraft collided with the terrain."
North Star Air is a Thunder Bay-based airline that largely serves First Nations in northern Ontario.
The investigation found parts of the company's work culture emphasized getting the job done, rather than following regulations, and pilots took unnecessary risks, like not relying on their instruments in poor weather. The pilot and co-pilot also did not file a flight plan and weren't wearing their shoulder harnesses, the report says.
It also found the company lacked oversight over pilots who engaged in risky behaviour, with no one from management supervising day-to-day operations for DC3 pilots.
"The absence of direct supervision meant that company pilots had considerable latitude when it came to making operational weather-related decisions," the report said. "Over time, a subculture ... developed amongst some DC3-TP67 pilots and went undetected by the company management team."
Following the crash, the company brought in a quality-control program, and a 2020 followup inspection from Transport Canada found the airline effectively fixed its issues, the TSB report says.
North Star Air's president and chief operating officer responded to the report after it was released, saying the changes the company made following the crash have continued.
"We took immediate action including procedural and personnel changes within our DC3 operation. It was just a small group of individuals with that operation we had to address," said Jeff Stout.
Those procedural changes included filing paperwork correctly, such as flight plans, and better observance of safety procedures.
"The changes we took had, we believe, an immediate and profound effect, not just within our DC3 operation, but within our entire company in bolstering our safety culture," he said.
In the last two years, Transport Canada has audited the company twice, and neither has found any issues, Stout said.
"The team has a lot to be proud of in terms of the changes we've made."